Bill Text: TX HB3924 | 2021-2022 | 87th Legislature | Enrolled
Bill Title: Relating to health benefits offered by certain nonprofit agricultural organizations.
Spectrum: Slight Partisan Bill (Republican 26-9)
Status: (Passed) 2021-06-18 - Effective on 9/1/21 [HB3924 Detail]
Download: Texas-2021-HB3924-Enrolled.html
H.B. No. 3924 |
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relating to health benefits offered by certain nonprofit | ||
agricultural organizations. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended | ||
by adding Chapter 1275 to read as follows: | ||
CHAPTER 1275. BALANCE BILLING PROHIBITIONS AND OUT-OF-NETWORK | ||
CLAIM DISPUTE RESOLUTION FOR CERTAIN PLANS | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 1275.001. DEFINITIONS. In this chapter: | ||
(1) "Enrollee" means an individual enrolled in a | ||
health benefit plan to which this chapter applies. | ||
(2) "Usual and customary rate" means the relevant | ||
allowable amount as described by the applicable master benefit plan | ||
document. | ||
Sec. 1275.002. APPLICABILITY OF CHAPTER. This chapter | ||
applies to a health benefit plan offered by a nonprofit | ||
agricultural organization under Chapter 1682. | ||
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. | ||
(a) The administrator of a health benefit plan to which this | ||
chapter applies shall provide written notice in accordance with | ||
this section in an explanation of benefits provided to the enrollee | ||
and the physician or health care provider in connection with a | ||
health care or medical service or supply provided by an | ||
out-of-network provider. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1275.051, 1275.052, or 1275.053, as applicable; | ||
(2) the total amount the physician or provider may | ||
bill the enrollee under the enrollee's health benefit plan and an | ||
itemization of copayments, coinsurance, deductibles, and other | ||
amounts included in that total; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of mediation | ||
or arbitration, as applicable, under Chapter 1467. | ||
(b) The administrator shall provide the explanation of | ||
benefits with the notice required by this section to a physician or | ||
health care provider not later than the date the administrator | ||
makes a payment under Section 1275.051, 1275.052, or 1275.053, as | ||
applicable. | ||
Sec. 1275.004. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION. | ||
Chapter 1467 applies to a health benefit plan to which this chapter | ||
applies, and the administrator of a health benefit plan to which | ||
this chapter applies is an administrator for purposes of that | ||
chapter. | ||
SUBCHAPTER B. PAYMENTS FOR CERTAIN SERVICES; BALANCE BILLING | ||
PROHIBITIONS | ||
Sec. 1275.051. EMERGENCY CARE PAYMENTS. (a) In this | ||
section, "emergency care" has the meaning assigned by Section | ||
1301.155. | ||
(b) The administrator of a health benefit plan to which this | ||
chapter applies shall pay for covered emergency care performed by | ||
or a covered supply related to that care provided by an | ||
out-of-network provider at the usual and customary rate or at an | ||
agreed rate. The administrator shall make a payment required by | ||
this subsection directly to the provider not later than, as | ||
applicable: | ||
(1) the 30th day after the date the administrator | ||
receives an electronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim; or | ||
(2) the 45th day after the date the administrator | ||
receives a nonelectronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim. | ||
(c) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill an enrollee in, and the enrollee does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, and deductible under the enrollee's health benefit | ||
plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) if applicable, a modified amount as | ||
determined under the administrator's internal appeal process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
Sec. 1275.052. OUT-OF-NETWORK FACILITY-BASED PROVIDER | ||
PAYMENTS. (a) In this section, "facility-based provider" means a | ||
physician or health care provider who provides health care or | ||
medical services to patients of a health care facility. | ||
(b) Except as provided by Subsection (d), the administrator | ||
of a health benefit plan to which this chapter applies shall pay for | ||
a covered health care or medical service performed for or a covered | ||
supply related to that service provided to an enrollee by an | ||
out-of-network provider who is a facility-based provider at the | ||
usual and customary rate or at an agreed rate if the provider | ||
performed the service at a health care facility that is a | ||
participating provider. The administrator shall make a payment | ||
required by this subsection directly to the provider not later | ||
than, as applicable: | ||
(1) the 30th day after the date the administrator | ||
receives an electronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim; or | ||
(2) the 45th day after the date the administrator | ||
receives a nonelectronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim. | ||
(c) Except as provided by Subsection (d), an out-of-network | ||
provider who is a facility-based provider or a person asserting a | ||
claim as an agent or assignee of the provider may not bill an | ||
enrollee receiving a health care or medical service or supply | ||
described by Subsection (b) in, and the enrollee does not have | ||
financial responsibility for, an amount greater than an applicable | ||
copayment, coinsurance, and deductible under the enrollee's health | ||
benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) if applicable, a modified amount as | ||
determined under the administrator's internal appeal process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care or medical service: | ||
(1) that an enrollee elects to receive in writing in | ||
advance of the service with respect to each out-of-network provider | ||
providing the service; and | ||
(2) for which an out-of-network provider, before | ||
providing the service, provides a complete written disclosure to | ||
the enrollee that: | ||
(A) explains that the provider does not have a | ||
contract with the enrollee's health benefit plan; | ||
(B) discloses projected amounts for which the | ||
enrollee may be responsible; and | ||
(C) discloses the circumstances under which the | ||
enrollee would be responsible for those amounts. | ||
Sec. 1275.053. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER | ||
OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section, | ||
"diagnostic imaging provider" and "laboratory service provider" | ||
have the meanings assigned by Section 1467.001. | ||
(b) Except as provided by Subsection (d), the administrator | ||
of a health benefit plan to which this chapter applies shall pay for | ||
a covered health care or medical service performed for or a covered | ||
supply related to that service provided to an enrollee by an | ||
out-of-network provider who is a diagnostic imaging provider or | ||
laboratory service provider at the usual and customary rate or at an | ||
agreed rate if the provider performed the service in connection | ||
with a health care or medical service performed by a participating | ||
provider. The administrator shall make a payment required by this | ||
subsection directly to the provider not later than, as applicable: | ||
(1) the 30th day after the date the administrator | ||
receives an electronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim; or | ||
(2) the 45th day after the date the administrator | ||
receives a nonelectronic claim for those services that includes all | ||
information necessary for the administrator to pay the claim. | ||
(c) Except as provided by Subsection (d), an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider or a person asserting a claim as an agent or assignee of | ||
the provider may not bill an enrollee receiving a health care or | ||
medical service or supply described by Subsection (b) in, and the | ||
enrollee does not have financial responsibility for, an amount | ||
greater than an applicable copayment, coinsurance, and deductible | ||
under the enrollee's health benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) if applicable, the modified amount as | ||
determined under the administrator's internal appeal process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care or medical service: | ||
(1) that an enrollee elects to receive in writing in | ||
advance of the service with respect to each out-of-network provider | ||
providing the service; and | ||
(2) for which an out-of-network provider, before | ||
providing the service, provides a complete written disclosure to | ||
the enrollee that: | ||
(A) explains that the provider does not have a | ||
contract with the enrollee's health benefit plan; | ||
(B) discloses projected amounts for which the | ||
enrollee may be responsible; and | ||
(C) discloses the circumstances under which the | ||
enrollee would be responsible for those amounts. | ||
SECTION 2. The heading to Subtitle K, Title 8, Insurance | ||
Code, is amended to read as follows: | ||
SUBTITLE K. CERTAIN BENEFITS AND ARRANGEMENTS THAT ARE NOT | ||
INSURANCE [ |
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SECTION 3. Subtitle K, Title 8, Insurance Code, is amended | ||
by adding Chapter 1682 to read as follows: | ||
CHAPTER 1682. HEALTH BENEFITS PROVIDED BY CERTAIN NONPROFIT | ||
AGRICULTURAL ORGANIZATIONS | ||
Sec. 1682.001. DEFINITIONS. In this chapter: | ||
(1) "Nonprofit agricultural organization" means an | ||
organization that: | ||
(A) is exempt from taxation under Section 501(a), | ||
Internal Revenue Code of 1986, as an organization described by | ||
Section 501(c)(5) of that code; | ||
(B) is domiciled in this state; | ||
(C) was in existence prior to 1940; | ||
(D) is composed of members who are residents of | ||
at least 98 percent of the counties in this state; | ||
(E) collects annual dues from its members; and | ||
(F) was created to promote and develop the most | ||
profitable and desirable system of agriculture and the most | ||
wholesome and satisfactory conditions of rural life in accordance | ||
with its articles of organization and bylaws. | ||
(2) "Nonprofit agricultural organization health | ||
benefits" means health benefits: | ||
(A) sponsored by a nonprofit agricultural | ||
organization or an affiliate of the organization; | ||
(B) offered only to: | ||
(i) members of the nonprofit agricultural | ||
organization; and | ||
(ii) family members of members of the | ||
nonprofit agricultural organization; | ||
(C) that are not provided through an insurance | ||
policy or other product the offering or issuance of which is | ||
regulated as the business of insurance in this state; and | ||
(D) that are deemed by the nonprofit agricultural | ||
organization to be important in assisting its members to live long | ||
and productive lives. | ||
(3) "Preexisting condition" means a condition present | ||
before the effective date of an individual's enrollment in | ||
nonprofit agricultural organization health benefits. | ||
Sec. 1682.002. NONPROFIT AGRICULTURAL ORGANIZATION HEALTH | ||
BENEFITS AUTHORIZED. A nonprofit agricultural organization or an | ||
affiliate of the organization may offer in this state nonprofit | ||
agricultural organization health benefits. | ||
Sec. 1682.003. WAITING PERIOD FOR PREEXISTING CONDITION. | ||
Notwithstanding any other provision of this chapter, a nonprofit | ||
agricultural organization that offers nonprofit agricultural | ||
organization health benefits may not require a waiting period of | ||
more than six months for treatment of a preexisting condition | ||
otherwise included in nonprofit agricultural organization health | ||
benefits. | ||
Sec. 1682.004. REQUIRED DISCLOSURE BY NONPROFIT | ||
AGRICULTURAL ORGANIZATION. (a) A nonprofit agricultural | ||
organization that offers nonprofit agricultural organization | ||
health benefits must provide to an individual applying for | ||
nonprofit agricultural organization health benefits written notice | ||
that the benefits are not provided through an insurance policy or | ||
other product the offering or issuance of which is regulated as the | ||
business of insurance in this state. | ||
(b) An individual must sign and return to the nonprofit | ||
agricultural organization the notice described by Subsection (a) | ||
before the individual may enroll in nonprofit agricultural | ||
organization health benefits. The nonprofit agricultural | ||
organization must: | ||
(1) maintain a copy of the signed written notice for | ||
the duration of the term during which the nonprofit agricultural | ||
organization health benefits are provided to the individual; and | ||
(2) at the request of the individual, provide a copy of | ||
the written notice to the individual. | ||
Sec. 1682.005. NONPROFIT AGRICULTURAL ORGANIZATION NOT | ||
ENGAGED IN BUSINESS OF HEALTH INSURANCE. Notwithstanding any other | ||
provision of this code, for the purposes of offering nonprofit | ||
agricultural organization health benefits, a nonprofit | ||
agricultural organization that acts in accordance with this chapter | ||
is not a health insurer and is not engaging in the business of | ||
health insurance in this state. | ||
Sec. 1682.006. RISK TRANSFER OR COVERAGE. A nonprofit | ||
agricultural organization that offers nonprofit agricultural | ||
organization health benefits under this chapter may contract with a | ||
company authorized to engage in the business of insurance in this | ||
state that is not under common control with the nonprofit | ||
agricultural organization to: | ||
(1) transfer to that company all or a portion of the | ||
organization's risks arising from nonprofit agricultural | ||
organization health benefits offered under this chapter; or | ||
(2) obtain insurance coverage from the company | ||
guarantying the nonprofit agricultural organization's obligations | ||
arising from nonprofit agricultural organization health benefits | ||
offered under this chapter. | ||
SECTION 4. This Act takes effect September 1, 2021. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 3924 was passed by the House on May 5, | ||
2021, by the following vote: Yeas 106, Nays 39, 1 present, not | ||
voting; and that the House concurred in Senate amendments to H.B. | ||
No. 3924 on May 28, 2021, by the following vote: Yeas 104, Nays 42, | ||
2 present, not voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 3924 was passed by the Senate, with | ||
amendments, on May 22, 2021, by the following vote: Yeas 18, Nays | ||
11. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: __________________ | ||
Date | ||
__________________ | ||
Governor |